Provider Demographics
NPI:1932166097
Name:BENCOMO, KRISTEN MARIE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:MARIE
Last Name:BENCOMO
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:831 RIVECON AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-7323
Mailing Address - Country:US
Mailing Address - Phone:321-303-4569
Mailing Address - Fax:407-382-5637
Practice Address - Street 1:1525 S ALAFAYA TRL
Practice Address - Street 2:SUITE 101
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32828-8926
Practice Address - Country:US
Practice Address - Phone:321-303-4569
Practice Address - Fax:407-382-5637
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-01
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ 3383235Z00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL8902925 00Medicaid